Corrective Action Plans

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U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
View Audit 370140 Questioned Costs: $1
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
View Audit 370140 Questioned Costs: $1
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting
Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely subm...
Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely submission and retention of supporting documentation for required sponsor reporting. This process will be implemented by December 31, 2025.
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.
Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to b...
Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to be Completed by October 1, 2025
Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of nonc...
Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of noncompliance since using this platform. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: Done ‐ July 31, 2024
Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance...
Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance procedures and concurs with the finding. During the period, responsible departments—including the finance and accounting and human resources teams—experienced unexpected turnover, a significant shortage of staffing, and a time reporting system conversion. As a result, certain compliance procedures were not performed consistently and timely, resulting in unintentional noncompliance with respect to allowable costs, cash management, and reporting controls. Corrective actions: The Executive Leadership Team reviewed the staffing needs of the finance and accounting and human resources teams in 2024. Hiring and training staff to achieve a full team was established as key objectives for the Executive Leadership Team in early 2025. As of September 2025, all vacant positions in both teams have either been filled or have been posted and are in active hiring process. The Chief Financial Officer and Chief of Human Resources have reviewed all internal procedures related to award compliance and will ensure that compliance is timely and well documented going forward. Specifically, the Chief Financial Officer will ensure that purchase orders, invoices, financial reports, and performance reports are completed, reviewed, and approved prior to submission and funding. These processes will have additional oversight by the Chief Executive Officer, with assistance from the newly established Compliance Department, and the Board of Trustees. Responsible parties for corrective actions: The Chief Financial Officer will have direct responsibility for award compliance and will be supported by Chief of Human Resources. The Chief Executive Officer, Tiffany A. Tate, with assistance from the newly established Compliance Department, will confirm that compliance occurs on a timely basis and prior to submission and funding. Separately, the Chief Financial Officer will report on progress to the Audit & Finance Committee of the Board of Trustees. The Executive Leadership Team will be responsible for ensuring the finance and accounting and human resources teams achieve and maintain full staffing levels. Anticipated completion date: The organization is actively implementing the corrective actions by ensuring sufficient staffing as mentioned above and training to ensure prior approval of all grant reports and drawdown requests. As of October 1, 2025, all grant reports will be appropriately approved and documented as such.
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT sys...
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are ma...
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are maintained. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan for Finding 2024-002 Finding 2024-002 – Allowable Costs - Assistance Listing: 14.251 – Economic Development Initiative, Community Project Funding and Miscellaneous Grants Federal Agency: U.S. Department of Housing and Urban Development (HUD) Views of Responsible Officials: The...
Corrective Action Plan for Finding 2024-002 Finding 2024-002 – Allowable Costs - Assistance Listing: 14.251 – Economic Development Initiative, Community Project Funding and Miscellaneous Grants Federal Agency: U.S. Department of Housing and Urban Development (HUD) Views of Responsible Officials: The Organization concurs with the auditor’s finding and appreciates the feedback provided. We acknowledge that documentation submitted in support of draw requests did not always align precisely with the accounting records, specifically the profit and loss by class. Although there were sufficient allowable costs incurred during the audit period to support the drawdowns, we understand that consistency between supporting documentation and accounting system records is essential for compliance with Federal requirements. Corrective Action Plan: We are in the process of developing formal written procedures for managing draw requests under federal awards. These procedures will include verifying that all draw requests are supported by invoices or expenditure documentation that is properly coded in the accounting system. Ensuring that supporting documentation submitted for reimbursement exactly matches the accounting entries, both in amount and coding (by class/funding source). Because the Organization is relatively new to managing federal awards, we will provide targeted training to accounting and program staff on draw request preparation and review. Responsible Official: Bev Kurokawa, treasurer Email: bevk2323@gmail.com Phone: 808 281-3586 Expected Completion Date: December 31, 2025
CORE, Powered by The Rogers Foundation has discontinued the use of the Payroll Action Forms for tracking labor allocations. As of August 2025, all grant-funded positions have been converted to hourly status, with time and effort now documented directly by employees through Paylocity, the Organizatio...
CORE, Powered by The Rogers Foundation has discontinued the use of the Payroll Action Forms for tracking labor allocations. As of August 2025, all grant-funded positions have been converted to hourly status, with time and effort now documented directly by employees through Paylocity, the Organization’s timekeeping system. Employees clock in and out and designate the appropriate labor allocations for each portion of their workday. Human Resources pulls the Paylocity timecard reports for all grant-funded positions for each pay period. These timecards undergo a documented, multi-level review and approval process: first by the Program Manager, then by the Grant Manager. Approved timecards are uploaded to a secure shared drive, where the Grant Accountant uses them to prepare Requests for Reimbursement (RFRs). Before submission, the Grant Manager performs a final review of all expenses and supporting documentation and provides written sign-off on the total amount. CORE, Powered by The Rogers Foundation has designed and implemented, multi-level internal control system to ensure all payroll charges are properly authorized, supported, and retained prior to inclusion in RFRs, thereby preventing recurrence of the issue identified in the audit.
Federal Award Finding: Finding: 2024-002 Journal Entry Approval - Significant Deficiency in Internal Control over Compliance Name of Contact Person: John Cutter Corrective Action: - Extend the above policy specifically to federal grant-related transactions. - Require grant manager or finance directo...
Federal Award Finding: Finding: 2024-002 Journal Entry Approval - Significant Deficiency in Internal Control over Compliance Name of Contact Person: John Cutter Corrective Action: - Extend the above policy specifically to federal grant-related transactions. - Require grant manager or finance director review for any adjusting entries impacting federal awards. - Ensure that all adjustments are clearly tied to grant documentation and compliance rules (Uniform Guidance 2 CFR 200). Proposed Completion Date: September 30, 2025
Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more ...
Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more in-depth federal award process and collaborate with project partners to ensure their understanding of the compliance requirements as per Uniform Guidance (UGG) 2 CFR 200.303. The Foundation will also begin internal monitoring to ensure project partners are following established policies and procedures through the duration of each award. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by December 31, 2025.
Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management's Corrective Actions: During 2025, Hamilton County Area Neighborhood Development, Inc. (HAND) hired a con...
Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management's Corrective Actions: During 2025, Hamilton County Area Neighborhood Development, Inc. (HAND) hired a controller to assist with the preparation of the parent company and subsidiaries financials while instituting improved internal control policies. As such, HAND with the assistance of its controller will establish effective internal control systems to ensure the compliance with the requirements for grant agreements and cash management compliance requirements
Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grant...
Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grants, the Organization was unable to provide enrollment forms or supporting documentation. These forms are necessary to verify that participants met the program's eligibility criteria. YWCA Response- The YWCA Victim Services acknowledges this finding and has implemented the following corrective action plan to ensure compliance. Corrective Action Plan - Procedures exist to ensure all clients are enrolled and eligible for services under the STOP grant. In addition to documentation in the Apricot system, an additional legal screening process and intake forms are used to determine eligibility and complete client enrollment within a Victim Services application called MyCase. During the audit, documentation for the four identified cases from MyCase was erroneously excluded, causing the finding. As a subsequent event, the documentation for intake and eligibility for the four identified cases was provided to the external auditors. This process will continue, and future audits will include client documentation for both systems. Additionally, Enforcement of enrollment procedures within Apricot, and oversight from department Directors, has been made a priority. Time Frame for Correction -Appropriate procedures were in place during the full audit year of 2024 and will continue into future years. Corrective action related to documentation within the Apricot system was implemented in August 2025. Individuals Responsible - Jessica Glynn, Vice President of Victim Services and Kellie Swikoski, Grant Manager.
View Audit 369986 Questioned Costs: $1
2024-002 - Lack of Independent Review and Approval Auditor Description of Condition and Effect: During our testing of Allowable Costs/Cost Principles, of the 12 items tested, we noted all 12 instances where time sheets were missing evidence of review and approval. In addition, there was no evidence ...
2024-002 - Lack of Independent Review and Approval Auditor Description of Condition and Effect: During our testing of Allowable Costs/Cost Principles, of the 12 items tested, we noted all 12 instances where time sheets were missing evidence of review and approval. In addition, there was no evidence of review and approval of the hourly rate or salary for all the employees tested. During Cash Management testing, of the three items tested, all three drawdown requests were missing evidence of review and approval. Finally, during our testing of Reporting, all four of the reports selected for testing lacked evidence of review and approval. The Organization did not comply with the federal requirements as noted per 2 CFR 200.303. Auditor Recommendation: We recommend the Organization adheres to their internal control process of an independent review and approval of transactions, cash management and reporting related to federal grant programs. Corrective Action: While the Organization has controls in place to ensure proper review and approval, Management will ensure to have this process documented going forward. Responsible Person: Dora Gonzales Anticipated Completion Date: December 2025
2024-004 Water and Waste Disposal Loans and Grants (Section 306C) (Not A Major Program) Reserve Account The Finance Department will transferer the amount of $151,462 to fully fund the Reserve Account to meet the $201,982 balance required by the loan agreement. Starting in Fiscal Year 2025-2026, LRA’...
2024-004 Water and Waste Disposal Loans and Grants (Section 306C) (Not A Major Program) Reserve Account The Finance Department will transferer the amount of $151,462 to fully fund the Reserve Account to meet the $201,982 balance required by the loan agreement. Starting in Fiscal Year 2025-2026, LRA’s Finance Department will implement within its monthly accounting closing procedures the reconciliation and review of all transfers from General Account to Reserve Account. The monthly reconciliations and review will provide full compliance with USDA reserve account requirements, eliminates repeated findings in future audits and will improve transparency in reporting strengthening accountability and reduced risk of federal payments. LRA Finance Department will establish a formal review process to ensure all prior year findings are properly tracked and resolved. Jamille E Muriente Díaz, Financial Affair Director Telephone: 787-705-7188 Email: Jamille.muriente@lra.pr.gov Target Completion Date - 6/30/2026
All reimbursement claims submitted under federal or state food service programs shall undergo documented management review prior to submission, in compliance with 2 CFR §200.303 and program requirements. Claims must be signed and dated by the Program Director (or designee) and reviewed by the CEO or...
All reimbursement claims submitted under federal or state food service programs shall undergo documented management review prior to submission, in compliance with 2 CFR §200.303 and program requirements. Claims must be signed and dated by the Program Director (or designee) and reviewed by the CEO or CFO on a sample basis to verify compliance.
Finding 2024-004 – Key Personnel Requirements ● Issue: No internal controls to track/approve changes in key personnel (repeat of 2023-007). ● Corrective Actions: 1. Formalize procedures for notifying federal funders of personnel changes. ● Responsible Party: Operations Manager, Executive Director ● ...
Finding 2024-004 – Key Personnel Requirements ● Issue: No internal controls to track/approve changes in key personnel (repeat of 2023-007). ● Corrective Actions: 1. Formalize procedures for notifying federal funders of personnel changes. ● Responsible Party: Operations Manager, Executive Director ● Timeline: Finalize procedure by December 2025.
2024 – 001 Reporting (Compliance, Internal Controls Over Compliance) Material Weakness – ALN 10.767 Intermediary Relending Program Condition: Testing of the reporting requirements disclosed that the quarterly and semiannual IRP reports were not submitted to USDA Rural Development. Corrective Action ...
2024 – 001 Reporting (Compliance, Internal Controls Over Compliance) Material Weakness – ALN 10.767 Intermediary Relending Program Condition: Testing of the reporting requirements disclosed that the quarterly and semiannual IRP reports were not submitted to USDA Rural Development. Corrective Action Plan: BASEC management and staff has taken USDA Rural Development provided LINC training on September 30, 2025 and has been in contact with Clark Guthmiller, IRP specialist with USDA Rural Development. BASEC has implemented a procedure with IRP reporting to be done the month following the quarter end (April, July, October and January). The procedure includes the following steps: 1. In Porfol (loan software), Executive Director will review the Master Loan List for IRP Direct and IRP Revolved for quarter end to ensure all IRP loans are listed and all payment information is current as of month end. 2. Executive Director will then pull the Delinquency report to ensure IRP (revolved and direct) delinquency statuses. 3. Executive Assistant will review that all IRP loans are up to date and payment information is accurate and return to Executive Director 4. Executive Director will log into LINC (USDA system for loan reporting) and update the loan information and submit each month after quarter end. BASEC’s IRP approaching year budget will be submitted to USDA Rural Development by October 31st to allow time for any questions or corrections to ensure an approval from USDA prior to the new year. Emily Rodgers Executive Director
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